Pre-Designation: A Sixty-Second Seminar in Workers’ Compensation Claims Handling

It is common knowledge that most applicant attorneys view Medical Provider Networks (MPNs) as a program created for the benefit of employers. As a result, applicant attorneys do not consider MPN physicians as being unbiased but rather, they believe them to be in “cahoots” with the employer to the detriment of injured workers. After all, the employer was the one who established the MPN and selected its member physicians.  With that said, the applicant’s bar usually makes it a point to instruct workers at union meetings and other gatherings to opt-out of an MPN whenever possible by pre-designating a primary treating physician. In plain language, proper pre-designation allows an employee to escape an MPN.

Examiners are often taught that upon notice of a claim they should ask the employer if the worker pre-designated a primary care physician.  If so, the injured worker is allowed to seek treatment from the pre-designated physician, even when the physician is outside the MPN. The purpose of today’s blog is to advise employers and claims administrators that it is not enough to simply inquire if a worker pre-designated a primary care physician. The claim administrator must investigate further to determine if the pre-designation was proper. After all, accepting the validity of a designation at face value eliminates the ability of an employer to subjects the injured worker to MPN control.

The rules of pre-designation are numerous but generally simple:

1. The pre-designation must be submitted in writing prior to the industrial injury.
2. No particular form is required (although Form 9783 is offered by the DWC, such offer is for convenience purposes only – its use is not mandatory).
3. The worker must have health insurance from any source at the time of industrial injury.
4. The predesignated physician must agree to pre-designation prior to injury, but their agreement need not be in writing.
5. The pre-designated physician must have previously directed the employee’s medical treatment and retain their medical records, including medical history.
6. The pre-designated physician must be a “personal physician” which means the applicant’s regular physician or surgeon, including a doctor of osteopathy, licensed pursuant to Business and Professions Code 2000, et seq.
7. A medical group, such as Kaiser or the V.A., may be designated as a personal physician provided that the group is a single corporation or partnership composed of licensed medical doctors or osteopathy that operates an integrated multispecialty medical group providing comprehensive medical serviced predominantly for nonoccupation injuries and illnesses.
8. With respect to chiropractors:
   1. If an MPN exists, the pre-designated physician cannot be a chiropractor.
   2. If an MPN does not exist a chiropractor may be pre-designated; however, following an injury the employee must first be examined by a physician of the employer’s choice. If additional medical care is required after the initial medical visit, then the employee may request a transfer in writing to the pre-designated chiropractor for follow up treatment.

As stated earlier, a claims adjuster should verify that the pre-designation complies with the above requirements.  Any error will disqualify the pre-designation.  Employers should also be cautioned that it is a violation of LC 132a to discriminate against an employee for exercising their right to pre-designate.  Of importance, it should be noted that absent employee authorization, an employer is not allowed to contact the pre-designated physician prior to injury to verify compliance with pre-designation requirements. Also, if the pre-designated physician requires a consultation or referral to another physician, the pre-designated doctor may select a physician outside the network. However, if the referred physician should require yet another referral, then the referred physician must select someone from within the employer’s MPN.